Re: "Your Guide to Tracking Infections" (Manager's Guide to Infection Control, May Supplement, page 61). The first step in tracking infections is to capture all the cases your facility did and all the surgical site infections (SSIs) that occurred. Without accurate rates by various subgroups of your caseload, it's hard to make valid conclusions. The challenge is in capturing all SSIs. Relying on surgeon self-reporting is risky. A 30-day, direct patient contact is a more accurate way.

Anesthesia may be more responsible for SSIs than the surgeon, just as the surgeon may be more responsible for PONV than the anesthetist. Anesthesia contributes to wound infection through timing of antibiotics, body temperature control and IV contamination. Razor preps and glucose control (<150 mg/dL) contribute more to SSIs than many of the items you listed (such as PACU times).

David W. Edsall, MD
Director of Quality Control, Anesthesiology
Eastern Maine Medical Center
Bangor, Maine
[email protected]

Where Have Ethics Gone?
Re: "Negotiate Your Way to Lower Supply Costs" (January, page 48). The author recommends that you lie to surgical supply reps - "Even if you don't have another offer, make one up," he writes - then tries to cover himself by calling it savvy. Renaming it doesn't change the fact that he's recommending you lie to improve your bargaining position. I'm disappointed that ethics appears to have taken a backseat to saving a dollar. You can communicate that you expect to pay less than list price without lying.

Ronald D. Kratz, MD, MHA
Medical Director, Hershey Outpatient Surgery Center
Milton S. Hershey Medical Center
Hershey, Pa.
[email protected]

Dennis Fowler, RN, replies: I don't believe in lying to my vendors. If I'm already purchasing the item, I'll give them my exact prices, even invoices. If I'm starting cold, I like to come up with a figure. Some of what goes on in negotiating is a game, and I like to give myself the best chance of winning.

To Efficient Inhalational Anesthesia
Re: "Breathe In, Breeze Out" (May, page 59). Congratulations to Dr. Mayfield on a very well-written summary on improving the efficiency of inhalational anesthesia. In particular, I commend him on his recommendation to titrate the anesthesia to the target organ (the brain) using the BIS monitor.

To get past the legitimate criticism that the BIS doesn't predict patient movement, select the EMG as a secondary trace from the advanced screen and select "save" before exiting the screen. Although the EMG information is displayed in a bar graph above the BIS trend, between the SQI (signal to noise ratio) and the EEG, one's eye tends to notice the change in the EMG relatively late. Having the EMG trace appear below the BIS trend makes it obvious when the frontalis muscle is activated. A spike in the EMG is instantaneous while the BIS is 30 seconds delayed from real time.

Eliminate midazolam from the premedication and administer po clonidine 0.2mg (to patients weighing between 95 pounds and 175 pounds) 30 minutes to 60 minutes pre-op. The decrease in pre-op elevated catecholamine levels provides a de facto sense of tranquilization, reduces induction and maintenance anesthetic requirements for both propofol and inhalational agents by about 25 percent, and decreases PONV, post-operative shivering and pain management issues.

Barry L. Friedberg, MD
Corona del Mar, Calif.
[email protected]